QUICK TIPS
- Consider compounding with miconazole powder and hydrocortisone powder, if a corticosteroid/antifungal combination is necessary (which it rarely is). For example, hydrocortisone 1% or 0.5% ointment can be compounded with miconazole powder for short-term, careful external application, in cases of angular cheilitis.
- Limit your use of a topical corticosteroid for a fungal eruption (if one must be used) to the first few days of treatment. The corticosteroid class should be appropriate to the site of application.9
- Counsel your patients about the risks of using topical corticosteroids on thinskinned areas for more than a few days (few weeks, maximum). On the face, corticosteroids can cause rosacea and perioral dermatitis, as well as “rebound” vasodilation. Thus, topical corticosteroids should be used with great caution—and generally as a last resort—for chronic facial dermatoses.
Mistake #9: Corticosteroid underdosing and undercounseling
It’s not uncommon during the warm weather months for me to see patients who are near finishing a Medrol Dosepak that was prescribed by their primary care physicians for a case of contact dermatitis (eg, poison ivy). They come to me because the eruption has returned and it is “as bad as ever.”
Underdosing. Medrol Dosepaks are generally underpowered (too low a dosage) and too short a course.7,10,11
Undercounseling. Patients don’t always realize that contact dermatitis may actually last for 3 weeks or longer. They may also mistakenly believe that systemic treatment will get them through the whole episode (rather than the worst part).
QUICK TIPS
- Design your own prednisone taper for when such tapers are needed. You might even have the prescription, with taper, prefilled on paper for signature. for significant allergic contact dermatitis, the taper may last 2 weeks.
- Dispel myths. Assure patients that by taking a thorough soap shower (and laundering the clothing they were wearing), they will remove all of the oil responsible for the disease.
- Limit your use of injectable corticosteroids. There is little need for injectable corticosteroids in cases of contact dermatitis. Oral corticosteroids work just as well, can be more easily titered based on response, and pose no injection risk of tissue atrophy or abscess formation.9
Mistake #10: Requiring red flags in both history and exam
Skin diagnosis is an “or” game—not an “and” game. By that I mean: If either the history (eg, rapid change, bleeding, crusting, nonhealing ulcer) or the examination is worrisome, biopsy. Even dermoscopy can be completely reassuring with biopsy yielding a melanoma.12 Note, too, our earlier examples of patients with suspect examinations who gave reassuring histories of lesions that had been present for many years. Either a worrisome history or a suspect examination is sufficient for concern. Remember, in general, the worst-case scenario from a biopsy is a scar; from a missed melanoma, an autopsy report.
QUICK TIP
- Get back to basics. Look carefully at your patient’s skin—even if it’s not the reason for the visit. Take a moment to ask your patient: Do you have any changing lesions or is there anything on your skin that is scaly, bleeding, or crusting? Doing so will cut down on the number of patients who ultimately learn that the lesion that’s “always been there,” and that “didn’t worry the other doctors” is actually a skin cancer.
Correspondence
Gary N. Fox, MD, 1400 E 2nd St, Defiance, OH 43512; foxgary@yahoo.com